Kardelky, Wolfgang 115—
NEW YORK STATE DEPARTMENT OF HEALT!-I ` Pt 3
Vital Records Section ;#141. Burial - Transit Permit
°==34 Name First Middle Last Sex
Wolfgang E Karclky Male
Date of Death Age f Veteran of med For s,
E"#r May 20,2015 86 War or Da
Ems; Place of Death H,spital, In- or
Z City, Town or Village Glens Falls Str- ;,d p ¢" - Glens Falls Hospital
14
Manner of Death X Natural Cause n Accident Homicide Flikuicide . Undetermined Pending
ALI, ,, Circumstances Investigation
us Medical Certifier Name Title
Suzanne Bergin
"R Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed D. Register Number
.y City, Town or Village Glens Falls 5601 cQ 5
❑Burial Date metery or Crematory
II Entombment May 27,2015 a View Crematory
Address
ElCremation 21 Quaker Rd., Queensbury, NY 1
Date P d
Z I I Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
I Reinterment
Date Cemetery Address
Permit Issued to Registration Number
:, Name of Funeral Home Alexander-Baker Funeral Home 00037
• Address
-. 3809 Main Street,Warrensburg,NY 12885
s' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
VZ
Permission is hereby granted to dispose of the human &mains d cribed ab Date Issued OS1 ve ads Indic• ed.
7 gyp/� Re istrar of Vital Statistics (7 7i/
Registrar
, (signature)
- District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Li) �i �
Date of Disposition 61 i f t s' Place of Disposition ,
2" (address)
W.
CO
r (section) /a (lot number)C (grave number)
QName of Sexton or Person in Charge of Premises -]�^^''"�
Z (pfbase print)
WAs Signature Title 06'10--
(over)
DOH-1555 (02/2004)